Toenails. You don't have to cut them. Trust me. Just say no.

[GreenHousePub]

I don't order x-rays for heel pain....ever at 1st visit unless some crazy history. PF until proven otherwise. I am doing my part. In fact I rarely order x-rays. PT insertion pain? No x-ray, boot and steroid. Neuroma? No x-ray and inject. Achilles pain? No x-ray and boot steroids. Pain 3rd 4th met base no x-ray and boot vitamin D.
PP bros needing to pay for that expensive x-ray machine is who is ordering that crap.

To go on. Ankle gutter pain? Inject. Sinus tarsi pain? Inject. Peroneal pain? Boot and steroids.

When they come back the second visit and no better? Then I will get an x-ray. Rural outreach clinics with no x-ray teaches you how little you need it. Sure, every once in awhile you get burned. Recently had an 80-year-old dude that I diagnosed with Achilles tendonitis. Literally right at the insertion skin looked normal it was just really swollen and painful. No history.... Comes back about 2 weeks later said he was having some pain went to a local urgent Care they took an x-ray and there is a gigantic metal wire stuck almost all the way into his calc. No idea how he got it. Looked at it and said okay guess we're going to the or incision spread the Achilles part grab it with a pair of pliers irrigate close it back up good to go. Sure stuff like that's going to happen but that's not going to make me start ordering x-rays on everybody unnecessarily.

Yeah I'm still going to x-ray.

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[Feli]

Yeah I'm still going to x-ray.

100% ... it is crazy not to.

It is just not hard to say "left foot XRay" or "right ankle XRay" to your assistant and they write the order or go do it.

Basically, at the end of the day, you're held to the level of local peers and standard of care... so if ER and UCare or other nearby DPMs would XR (they would XR for pain, 100%), then you should too.

Our job is not to hope for the best (plantar fasciitis), it's to rule out the worst (stress fx, bone cyst/neoplasm, infection, Charcot, etc).

XR are informational (arch height, level of OA, etc etc). I have found multiple calc neoplasms, prior fx and even surgery the pts have not mentioned during H&P, had a Pediatrician who didn't initial XR a teen with forefoot pain (a needle in the foot, later turned abscess... at which time they called me). A lot of our patients aren't exactly A-plus historians (dementia, pedi pts, AMS, diabetics, developmental disability, etc etc).

Pain = XR.
Whether you own XR machine or get bonus for it or whether pt wants it is not the decision tree. If they have pain or wound or deformity and refuse (bunion not wanting surgery, afraid of expense, don't have time, etc), that's fine... just document that.

 

[GreenHousePub]

Basically, at the end of the day, you're held to the level of local peers and standard of care... so if ER and UCare or other nearby DPMs would XR (they would XR for pain, 100%), then you should too.

100%

Sometimes from what I am hearing here, it sounds like there are new mustaches forming on younger podiatrists.

Sure they aren't the fully waxed handlebars as before, but their own brand of mustache is coming in nicely.....maybe time for some wax.....dyeing it a little couldn't hurt....

 

[air bud]

Ok, can I x-ray thick fungal toenails that are PAINFUL?
Don't want this ground breaking thread to veer off course.

 

[GreenHousePub]

The only thread that hasn't veered off course somehow is the "free podiatry online billing resource" thread which I find painfully boring and don't participate in.

 

[Adam Smasher]

Ok, can I x-ray thick fungal toenails that are PAINFUL?
Don't want this ground breaking thread to veer off course.

good point. how many subungual exostoses are we missing?

 

[NatCh]

100%

Sometimes from what I am hearing here, it sounds like there are new mustaches forming on younger podiatrists.

Sure they aren't the fully waxed handlebars as before, but their own brand of mustache is coming in nicely.....maybe time for some wax.....dyeing it a little couldn't hurt....

LOL

 

[Adam Smasher]

100%

Sometimes from what I am hearing here, it sounds like there are new mustaches forming on younger podiatrists.

Sure they aren't the fully waxed handlebars as before, but their own brand of mustache is coming in nicely.....maybe time for some wax.....dyeing it a little couldn't hurt....

I think we should (in another thread if needed) try to solidify our definition of "mustache podiatrist" because it's becoming a lot like how in political debates "fascist" just means "someone I strongly disagree with"

 

[Hybrocure]

I think we should (in another thread if needed) try to solidify our definition of "mustache podiatrist" because it's becoming a lot like how in political debates "fascist" just means "someone I strongly disagree with"

Paging Utvolsdpm

 

[p100]

You practice in a park?

 

[NatCh]

The problem with trimming toenails is that it's like sex work.

I can already hear airbud and heybrother meming the hell out of this post, but I'm damn serious.

Anyone can do it, there's little talent and no intellect involved. On the one hand it's revolting and degrading. No parent would want this job for their kids. On the other hand there's money to be made, some build significant wealth. But material gain will only motivate you so much.

Then there are the more insidious effects on the person's psyche and relationships. If a woman works a day job as, say, a librarian, but on weekends she provides "content" online, is she a librarian who creates content? Or is she a content provider who works as a librarian? Does her day job even matter? For her self identity? For how she is perceived by others?

Same thing with us. Are we doctors who cut toenails? Or are we nail cutters who sometimes do actual doctoring? How many of us have surgically managed patients who ask us at some point along the way to trim their toenails? Why would they expect this? Why do they think it's an appropriate question? The more toenails we cut, the more it consumes our professional identity. There is no doctor-patient relationship, only transactions.

I should offer a caveat, there are plenty of nice politically correct arguments that sex work is real work, and we could probably retool those same arguments that nail care is real care. And that's my real intent here, not to critique anyone for plying their trade, just to draw the parallel.

However, sometimes economic realities force us into things. Airbud says there are other patients. I'm not so sure. We're up to 11 schools now, but not much else to be done for the foot. I cut toenails not because I choose to, but because I don't have any choice. I dream of quiet quitting and just telling all my toenail clients to f off so I can spend my days rendering actual care. The result would just be empty space on my schedule. So I continue on, a shoe-er of the unshod, a reducer of all things thick and mycotic. 🦞👑

...and they both smell bad?

 

[GreenHousePub]

I think we should (in another thread if needed) try to solidify our definition of "mustache podiatrist" because it's becoming a lot like how in political debates "fascist" just means "someone I strongly disagree with"

I'll volunteer that a mustache pod practices against standard of care of the overall medical community based on their strong personal beliefs/anecdotes.

Basically one-man islands who make our profession look terrible. Mainly a symptom of the isolation and second-tier status of podiatry.

It's how you get people who write into PMNews about how they are diagnosing neuropathic marijuana addicts or how they are outraged that the rib-back carbon blade isn't being taught.

Or the guy on LinkedIn brag-posting horrible "mis" bunions without fixation.

 

[Adam Smasher]

Is it mustache podiatry to love diabetic shoes because they reimburse profitably?

Or is it mustache podiatry to hate diabetic shoes (as I do) because of anecdotal observation that they don't work when you need them to (as I have)

 

[Sweatshirt]

Did an emergency rearfoot gas gangrene case yesterday. WBC was over 20, constitutionals up the wazoo, A1c 15%, smoker. Cut open his heel, essentially saved his life. POD #1 today. Dressing change. As I am walking out of the room....

"Hey doc can you do anything about these thick toenails?"

Everything comes back to toenails

 

[air bud]

Is it mustache podiatry to love diabetic shoes because they reimburse profitably?

Or is it mustache podiatry to hate diabetic shoes (as I do) because of anecdotal observation that they don't work when you need them to (as I have)

Well there are 2 sides to a mustache, similar to the duality presented here.

 

[Shiyuan]

Did an emergency rearfoot gas gangrene case yesterday. WBC was over 20, constitutionals up the wazoo, A1c 15%, smoker. Cut open his heel, essentially saved his life. POD #1 today. Dressing change. As I am walking out of the room....

"Hey doc can you do anything about these thick toenails?"

Everything comes back to toenails

How you prob felt inside 😂😂

 

[air bud]

I think we should (in another thread if needed) try to solidify our definition of "mustache podiatrist" because it's becoming a lot like how in political debates "fascist" just means "someone I strongly disagree with"

Sounds like something a mustache podiatrist would say.

You are a "mustachist?"

 

[Sweatshirt]

How you prob felt inside 😂😂

His future BKA will also fix those thick toenails

 

[Hybrocure]

Late night rearfoot gas I&Ds in podiatry are crucial, they allow the vascular surgeon to get uninterrupted sleep overnight so they can wake up refreshed and ready to do the BKA the next day.

 

[air bud]

Late night rearfoot gas I&Ds in podiatry are crucial, they allow the vascular surgeon to get uninterrupted sleep overnight so they can wake up refreshed and ready to do the BKA the next day.

Meme incoming. Going to take me some time. I am not calling dibs on this, feel free to meme.

 

[BubbaWub]

Late night rearfoot gas I&Ds in podiatry are crucial, they allow the vascular surgeon to get uninterrupted sleep overnight so they can wake up refreshed and ready to do the BKA the next day.

This has to be one of the best comments I have read on here. I spat out what I was drinking. Lord almighty this is too good.

 

[mandrew]

Did an emergency rearfoot gas gangrene case yesterday. WBC was over 20, constitutionals up the wazoo, A1c 15%, smoker. Cut open his heel, essentially saved his life. POD #1 today. Dressing change. As I am walking out of the room....

"Hey doc can you do anything about these thick toenails?"

Everything comes back to toenails

So true

 

[mandrew]

Don't do it. It's a not a service you offer. Don't do it. History of amputation and /or revascularization ok I will. Otherwise go to another podiatrist. It will be ok. There are other patients. Trust me. Don't do it.

Nails. Always nails.

In PP, you perform that service for your diabetic patients, always.

 

[Hybrocure]

So true

The worst is when you’re there doing real **** and then the family member asks you about the toenails.

 

[mandrew]

In PP, you perform that service for your diabetic patients, always.

Isn’t the main goal of our profession to PREVENT amputations?

 

[heybrother]

Isn’t the main goal of our profession to PREVENT amputations?

No, no, no. That's a subset of our profession called limb salvage. It has some marginal relevance and intersects with "podiatry cobblers" ie. diabetic shoe makers.

I have a very tailored calling focusing exclusively on plantar fasciitis and performing flexor tenotomies and 1st MPJ fusions. These to me are the Holy Trinity of podiatry.

 

[HardRoadPaved]

In PP, you perform that service for your diabetic patients, always.

Not if it's not medically necessary; otherwise it's just a cash service. Diabetes in of its self is not a reason to get a professional pedicure. Those with risk factors aka comorbidities that can lead to self injury doing it is a reason.